GW1--02900_Well Construction - GW1_20240510

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1.Well Contractor Information: ` '
GarrettClause ��'>�"-�; :�.`:�:� .�-,.��.�.� :.:��:�.,:- ,-�--
FR7O�M�� TO DESCRIPTION
Well Contractor Name �(,L3�ft V1 ft
4550-A ft ft
L?x0MEBl_ QS1N;G;(for�u i casg4/e717V4g� _.D'R `kc`abM -- t's1 ': •
NC Well Contractor Certiflcat onNumber �.r��
INCvF FROM f DIAMETER THICKNESS MATERIAL •
Morgan Well &Pump ft in. s 'a\ Qvc,
CompanyName /) ','6 7$1 I2 G G 012 C}BR_`T,C( eE'tliefISrlosed±'-lobp�','�;=-k E�f,J: ?�= 1. �t
W f/j^'-VIC`/�geCIS FROM TO DIAMETER THICKNESS MATaRTAL
2.WellConstructionPermit#: (,!/(i r V ft in
List all applicable well constntctionpennits(i.e.VIC,County,State, Variance,etc)
ft ft in.
3.WellUse(check well nse): tj ,�. ��r5_ -= t ;? �v�s
S.GI��+'T'L`Tl�.,r•�•. -3�" �;r-.-^�",•Y�w�i2v� �a._a�-w- r. '
Water Supply Well: FROM To DIAMETER SLOT s THICKNESs MATERIAL
gricultoral aMunicipal Public ft ft in.
Geothermal(Heating/Cooling Supply) i"'iResidential Water Supply(ogle) ft. ft m•
•
Al'esidential Water Su l shared .•_.- , T:ef3yfi -'=mac ti. -: - r ri t'' K'a ,
LI Industrial/Commercial Supply(shared) UFO QT
FROM TO /MATERIAL 1 - EMPLACEMENT OD&AMOUNT
Im . ® _ft lf'p ft �61-0,1-t_ pp,...1 f.,g3
Non-Water Supply Well: v�^
j Monitoring DiReCOVEly ft. ft.
•
Injection Well: ft ft
DI Aquifer Recharge in Groundwater Remediation y , zGgC, :aPPliatTej 7'i^`-`•vezmmswe-. �=i'E=mgs-
Salim . arripr FROM TO MATERIAL EMPLACEMENT METHOD
©IAquilrer Storage and Recovery � �`B ft ft
Aquifer Test f lStormwater Drainage •
Experimental Techicagy I0Subsidence Control •
ft. ft
•
®ITracer .�„0'9DTt IN �i0Cz,'-'(attacr'fi.!aka fional sh efx' nF'eeessa;~P1 r=a`�`_-liLiq: -�,'. 1
j Geothermal(Closed Loop) FROM . TO D C ISON(color m,hardness,saiUreektype,gra site,eta)
Geothermal(Heating/Cooling Return) �Other(explain under#21 Remarks) oa ft, "� ft y•O r
V 1--bv11 I Well ID# CY ft �O ft ,'(t t-'A �rr
4.Date Well(s)Completed: ��
• (3d ft ft S'cmck-= hs,c4--
5a Well Location:
i YeeDity1D#(if applicable) /()ft 25_,ft. �`1; JC{- ,l�
Fac�7ity/O`wfnerNam`e0 j� 1 • .�/�'-
%� ii- ,Yf" Shet c\\S �1t) t/�()ft. `�{G, ft (1 ) pre
ft ✓ ft J
and :-M-, ��u ti� ice• •mot_
• PhysicalAddress,City, Zip ....,-- a::,r.' _ _ .:.�;; _ •:�..-
County Parcel Identification No.(PIN) ` �� 4.,„., }'
5b.Latitude and longitude in degrees/mirintes/seconds or decimal degrees: jviAY 1 J 1014,
(1fwellfield,on let/long is suEcient) 22.Certification: •
5—'1 671 DI To 7S-5 ,r;f:,.,_-: -•,-._�..e;• o1 \ (21—e2/i •
Signature of Certified Well Contractor Date
• 6.Is(are)the well(s)V.'ena anent or �li Temporary - '
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or lNo • with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closell-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only l GW 1 is needed. Indicate TOTAL NUMBER of wells
construction.details. You may also attach additionalpages ifnecessary.- •
drilled: SUBMITTAL INSTRUCTIONS
9.Totalwell depth below laud surface: ��1') (R) 24a.For AIL Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfd ferent(example-3@200'and
2Qa 100) construotibn following:
to the
10.Static water level below top of casing: / (ft) Division of Water Resources,Information Processing Unit, ,
Ifwater level is above casing,use"-i• 1617 Mail Service Center,Raleigh,NC 27699-1617 -
•
11.Borehole diameter: 0 CuL 24b.For Injection Wells: In addition to sending the form to the address in 24a
• •'above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: � construction to the following.
•
(i.e.auger,rotary,cable,'direct push,etc.) •
•
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: fJ {� ' 1636 Man Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' Method oftest: l'f I' •i �- 'ta— 24c.For Water Supply&Injection Wells: In addition to sending the form to
• the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection Lyke:G,rei n A 64- ]�Amount v G 6 2' completion.of well construction to the county health department of the county
where constructed. .
Form W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016